Certified Independent Medical Examiner · PDF fileCertified Independent Medical Examiner CIME...

Certified Independent Medical Examiner

CIME

MEDICAL DOCTOR

CERTIFICATION INFORMATION Board of Registry Information Examination Information Application Information Examination Application Exam/Education Schedule

American Board of Independent Medical Examiners 6470-A Merritts Creek Road

Huntington, WV 25702 PH: 304-733-0095 OR Fax: 304-733-5243

[email protected] www.abime.org

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The ABIME Board of Registry

Upon certification, physicians are eligible for membership in the Board of Registry

The ABIME Board of Registry consists of Certified Physicians who pay an annual fee of $195 to qualify for the following menu of Activities, Programs, and Services.

Activities, Programs, and Services: ABIME is committed to keeping its members up to date in disability medicine by providing programs and services that foster professional development throughout their careers. The following is a partial list of informational and educational tools that keep member physicians at the top of their profession. All benefits, including subscriptions to publications, are activated upon receipt of the annual Board of Registry payment. • Members of the Board of Registry are eligible for the Alternate Pathway Recertification Program.

• Listing in the Print Directory and listing in the Directory online at www.abime.org.

• A subscription to DISABILITY MEDICINE- the quarterly journal of the American Board of Independent Medical Examiners.

• Discounted rates on ABIME education programs.

• New developments in programs including the Expert Witness, and Report Writing Seminars.

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Your colleagues are saying...

“Physicians who have excellent clinical skills in combination with a discerning understanding of the unique issues involved in a functional restoration/return to work, and are willing to document their findings and opinions objectively, are of great value to all

parties involved. ABIME certification implies an enhanced level of understanding of these important components”. Karen M. Wielde, RN, BSN, CCM, VP, Business Development Medical Legal, Best Doctors, Inc.

"I am more confident about doing quality evaluations and reports. In three months, my referral base doubled. The biggest problem I

have is the waiting list!" Rick Zabrodski, MD, CIME, Alberta, Canada

"As a result of my certification by ABIME, new clients requiring IMEs have sought out my services and have enhanced my referral

base. I recommend the ABIME certification process." Harvey Goldberg, MD, CIME, West Bay Shore, New York

The insurance industry is increasingly turning to ABIME-certified physicians to assist them with difficult cases:

"ABIME recognizes the need for very high quality Independent Medical Exams and has created a useful and practical process for

physicians to develop and enhance the requisite knowledge base and skill sets." Mark E. Battista, MD, Medical Director, UNUM Life Ins. Co. of America, Portland, Maine

"We are most interested in a timely, fair, and accurate independent medical evaluation and impairment rating. Training and examiner

accreditation will help achieve the consistency we demand." Barton G. Margoshes, MD, Vice President, Liberty Mutual Group, Medical Director, Risk Services, Boston, Mass.

"The need for trained physicians who understand the requirements for managing disability and focusing on the return to work aspects

for medical delivery is a significant value to the industry." Lester L. Sacks, MD, PhD, President, Medical Management Services Travelers Property Casualty Corporation, Hartford, Conn.

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What You Need to Know About ABIME

The prestigious distinction of certification through the American Board of Independent Medical Examiners (ABIME) sets you apart as a nationally recognized medical examiner. ABIME certification represents professional competency and integrity. Physicians certified by ABIME meet the demand for quality, impartial impairment and disability evaluations. ABIME has certified over 3000 physicians since 1996. ABIME certification is recognized as the national standard for physicians performing IMEs. ABIME meets today’s challenges for independent medical examiners Expectations for highly qualified medical examiners have never been greater. Insurance companies, workers’ compensation commissions, employers, and attorneys are continuously engaging independent medical examiners to assess challenging cases. Workers’ compensation and other disability cost total billions of dollars every year. As a result, cost-conscious organizations are closely scrutinizing medical providers. The needs of healthcare organizations, disability managers, employers and insurers have changed dramatically over the last decade. Biased, inadequate and superficial medical examinations are unacceptable in today’s competitive marketplace. The American Board of Independent Medical Examiners addresses the need for competent, reliable disability/compensation evaluations. Key leaders within the medical, legal and disability management communities established ABIME to: 1. Set and maintain high standards of conduct and performance among independent medical examiners 2. Identify and promote qualified individuals who meet these standards ABIME is incorporated as a national quality assurance board. It ensures uniformity of standards and competency of physicians performing independent medical and disability examinations. ABIME’s board of well-known experts from multiple disciplines regulates its application and examination process to identify qualified independent medical examiners. How ABIME certification advances your career: ABIME certification offers you a competitive advantage over non-certified physicians. Today, industry experts view certified independent medical examiners as better qualified to respond to the needs of case and claims management.

ABIME requirements for knowledge, skills and abilities qualify physicians to: ♦ Conduct superior, independent medical examinations ♦ Write comprehensive, accurate reports ♦ Interpret relevant workers’ compensation and disability law ♦ Provide credible, defensible testimony As an ABIME certified independent medical examiner, your credentials and advanced knowledge bring you: ♦ Significant recognition among your peers ♦ Added credibility with prospective clients ♦ Increased referrals and case assignments ♦ Greater practice and career expectations ABIME certification is a special distinction that sets you apart as one of the best in the field. Your achievement instills greater client confidence in your capabilities and professionalism, and identifies you as an experienced physician who understands the unique issues of disability evaluation.

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Qualifying for ABIME certification ABIME certification is granted to physicians who successfully achieve the following criteria: ♦ Continuing medical education in the performance of independent medical examinations and disability and impairment evaluation ♦ A selective application process meeting standards of education, experience and ethical conduct ♦ A signed agreement to abide by professional guidelines of conduct ♦ A competency examination covering such key aspects as clinical competency, behavioral science, impairment and disability systems, and the AMA Guides to the evaluation of Permanent Impairment ♦ Recertification is required every 5 years Why choose an ABIME-certified physician? The need for qualified medical evaluations continues to increase. ABIME certification provides value to physicians and a variety of clients including claims adjusters, case managers, employers, commissioners and attorneys. Certification identifies the physician as someone who: ♦ possesses necessary medical skills and training

in physical, behavioral, psychological and occupational assessment

♦ draws upon in-depth experience to perform credible evaluations

♦ provides a thorough, objective, written analysis regarding diagnosis, causation, prognosis, maximal medical improvement, impairment, work capacity, appropriateness of care and case management

♦ demonstrates skills in testifying as an expert medical witness

♦ recognizes the value of impartiality and thoroughness in case evaluation

♦ strives to conduct timely, cost-effective evaluations

♦ abides by ABIME guidelines of conduct and ethical practice

♦ exhibits commitment to professional excellence and integrity as a member of a select group of physicians

Certified independent medical examiners are an

essential resource for all types of disability management professionals. Their impartial and thorough assessments enhance the evaluation process and produce beneficial results for all involved, including the examinee. ABIME certified physicians are specially prepared to:

♦ clinically assess cases of disability ♦ identify relevant physical, behavioral,

psychological, psycho-social and occupational issues

♦ obtain medical information that may have been overlooked

♦ clarify issues of causation and apportion responsibility

♦ perform accurate impairment evaluations according to the AMA Guides to the Evaluation of Permanent Impairment

♦ assess work ability ♦ make recommendations about case

management

ABIME certification singles out exceptional independent medical examiners dedicated to performing quality evaluations and recognized for their unique qualifications.

Added Benefits of ABIME Certified physicians can choose to be listed in an annual ABIME National Directory of Certified Independent Medical Examiners available to prospective clients and organizations. The complete directory is available in an interactive database at www.abime.org. The national ABIME awareness campaign recognizes and promotes the expertise of ABIME-certified physicians.

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Guidelines of Conduct Each physician certified by the American Board of Independent Medical Examiners (ABIME) is expected to comply with these guidelines of conduct:

Accordingly, each physician should: 1. be honest in all communications; 2. respect the rights of the examinee and other participants, and treat these individuals with dignity and

respect; 3. at the examination:

a. introduce him/herself to the examinee as the examining physician; b. advise the examinee they are seeing him/her for an independent medical examination, and the

information provided will be used in assessment and presented in a report; c. provide the examinee with the name of the party requesting the examination; d. advise the examinee that no treating physician-patient relationship will be established; e. explain the examination process; f. provide adequate draping and privacy if the examinee needs to remove clothing for the

examination; g. refrain from derogatory comments; and h. close the examination by telling the examinee that the examination is over and ask if there is

further information the examinee would like to add; 4. reach conclusions that are based on facts and sound medical knowledge, and for which the

independent medical examiner has adequate qualifications to address; 5. be prepared to address conflict in a professional and constructive manner; 6. never accept a fee for services which is dependent upon writing a report favorable to the referral

service; and maintain confidentiality consistent with the applicable legal jurisdiction.

Medical Doctor Application Information

Eligibility Each applicant for certification as an independent medical examiner is required to meet specific eligibility requirements and satisfactorily complete a written examination. Eligibility criteria are determined by the American Board of Independent Medical Examiners (ABIME) Board of Directors. Recertification is required every five years. Certified physicians are required to pay a fee of $195 each year to be listed on the ABIME Board of Registry. The Board of Registry benefits include receipt of the Quarterly Journal “Disability Medicine”, the physician’s listing in the print and online directories, discounted rates on ABIME Education Programs, and special insurance programs.

These requirements are: • A current unrestricted state medical license illustrating the expiration date. • A record clear of any disciplinary action for an ethical or other offense as imposed by a state board of medical licensure

within the past 5 years. • Board certification in a specialty recognized by the American Board of Medical Specialists (ABMS) or the American

Osteopathic Association (AOA), or documentation that applicant has been involved in the practice of medicine, including residency years, for a period of 10 years prior to submitting an ABIME application.

• Within the one year prior to taking the examination, completion of at least 15 hours of ABIME Sponsored continuing medical education (AMA Category 1) in impairment rating and independent medical examination. (30 hours of CME in the field of impairment rating and independent medical examination are recommended.)

• Signed agreement to abide by the ABIME Guidelines of Conduct.

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Confidentiality Review of credentials for ABIME certification is completely confidential and privacy is protected. ABIME maintains only a list of ABIME Certified Independent Medical Examiners.

Fees The American Board of Independent Medical Examiners has instituted the following fees to better support our educational mission. Price of the examination: First attempt is $995.00 (US Funds). A check or money order payable to ABIME must accompany the application. Credit card payments are also accepted (Visa, MasterCard, or Amex). Requests to transfer must be made in writing and received in the ABIME office 14 days prior to the examination date and there will be a $100.00 charge for each transfer.

Certification/Directory Upon successful completion of the examination, the applicant will receive a certificate stating that he or she has been found to possess special knowledge as a Certified Independent Examiner (CIME). Certified physicians are required to pay a fee of $195 each year to be listed on the ABIME Board of Registry. The Board of Registry benefits include receipt of the Journal Disability Medicine, the physician’s listing in the print and online directories, discounted rates on ABIME education programs, and eligibility for recertification through the alternate pathway. Candidates who have taken the examination will be notified of the results within 60 days of the examination date.

Application Application requests may be directed to ABIME, 6470-A Merritts Creek Road, Huntington, WV 25702, or by calling (877) 523-1415. We request, but do not require, that your application be sent at least two weeks prior to the exam date. Please call the ABIME office to request permission for late registration.

ABIME reserves the right to cancel examinations based on registration numbers. Hotel reservations and travel arrangements are the sole responsibility of the examination registrant.

Recertification Ongoing developments in this rapidly changing arena require a certification time limit. Therefore, certification is valid for a five-year period following date of issuance, at which time certification expires. Requirements for Recertification by examination include: • A medical license, current and unrestricted; • A record clear of any disciplinary action for an ethical or other offense as imposed by a state board of medical licensure

within the past 5 years; • Evidence of completion of additional impairment and disability evaluation continuing medical education; • Signed agreement to abide by the ABIME Guidelines of Conduct; and • Satisfactory completion of the then current examination.

Recertification by Alternate Pathway allows physicians to recertify by compiling 60 points through a combination of continuing medical education courses and completion of Questions pertaining to articles listed in the ABIME Journal Disability Medicine.

Guidelines of Conduct Each applicant must agree to comply with the ABIME Guidelines of Conduct.

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EXAMINATION INFORMATION Introduction This booklet provides you with the information necessary to prepare for your upcoming examination by the American Board of

Independent Medical Examiners (ABIME), including: • General information • Instructions • Sample test items • Knowledge, Skills and Abilities/Test Outline • Bibliography The examination lasts no more than 4 hours in duration and consists of 120 multiple choice test items, distributed by content area according to the test blueprint. The exam includes recall, interpretation, and problem solving types of questions. State-of-the-art psychometric procedures are employed for scoring and determination of the minimum passing level. Scores are based upon the total number of items answered correctly. There is no penalty for guessing. ABIME recommends that applicants prepare adequately for the examination through readings, training, and experience.

Instructions Admission • Bring the ABIME examination confirmation letter with you to the examination room. • Report to the examination room promptly at the registration time indicated on the letter. Verify your name and social security

number with the information on the answer sheet you receive. Materials • All materials required to take the test (e.g., #2 pencils and applicable figures and tables from the AMA Guides to the Evaluation

of Permanent Impairment) will be provided. • You will not be permitted to bring any books, notes, electronic paging devices, recording or filming devices, radios, other

mechanical and/or electronic devices, beverages, or food into the testing room. Examination Procedures • At the appointed time, the Chief Proctor will begin the examination with introductory remarks. These include reading the

instructions and agreement form. You are required to follow proctor directions. You will receive an examination booklet immediately following the remarks.

• Read materials carefully and listen to directions given during the exam. • Do not communicate with any other examinee during the examination. If you are detected attempting to provide or receive

assistance, your test score will be invalidated. • If you must leave the test room temporarily, your identity must be verified before you are readmitted. You will not receive

additional testing time.

Finishing the Examination • Upon completing the examination, check your work. Be sure any erasures are complete and there are no stray marks which

could be counted as wrong answers. • Once you submit the examination booklet and the answer sheet to the proctors, these materials will not be returned to you for

additional review or completion.

Sample Test Items The following are examples of the types of multiple-choice questions you will see on the exam. Answers follow. 1. Which of the following statements about surgical treatment of sciatica from disk herniation is correct?

a. Surgically treated patients have less pain and better function than non-operated patients at 1 year follow-up but not long term. b. An MRI showing disk bulge on the same side as a patient's sciatica predicts a high probability of complete pain relief with surgery. c. Failure to respond to 2 weeks of conservative treatment is an indication for surgery.

d. After disk surgery, there is strong evidence the patient should never lift more than 25 lbs.

2. Which of the following is not characteristic of complex regional pain syndrome I (reflex sympathetic dystrophy)?

a. Pain out of proportion to the degree of injury b. Autonomic dysfunction c. Abnormal nerve conduction studies d. Abnormal bone scan

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3. Malingering: a. is another term for factitious disorder. b. may involve an unconscious motivation for symptoms associated with secondary gain. c. may lead to prosecution for fraud and should be diagnosed carefully. d. cannot exist in the presence of objective signs of injury. 4. According to the AMA Guides (5th Ed.), rating permanent

impairment involves assessing a condition that is stable and not likely to change substantially over the next:

a. 3 months. b. 6 months. c. 9 months. d. 12 months.

5. When measuring hip abduction, reliability can be increased by:

a. measuring the patient in the supine position using an inclinometer.

b. measurement in the prone position using a goniometer. c. consistent measurement from a well-defined starting position on each determination. d. measuring in the lateral decubitus position with the starting point in maximum adduction. 6. The Office of Workers Compensation Programs (OWCP)

was established to manage claims arising out of the: a. Federal Employers Liability Act (FELA). b. Merchant Marine Act ("Jones Act"). c. Social Security Administration. d. Federal Employees Compensation Act (FECA). 7. In a "slip and fall" personal injury suit against a restaurant involving a wrist fracture, the IME physician should:

a. report on and be prepared to testify as to whether or not the floor condition was an unreasonable hazard.

b. not report prior similar falls with successful suits, as that information is inadmissible. c. be prepared to testify according to, and cite in the report, Federal Rules of Evidence 25-29. d. record exams of central and lower extremity nervous system, cardiovascular evaluation including standing pulse and blood pressure

8. According to the AMA Guides (5th Edition), which of the following statements about range of motion measurements is incorrect? Range of motion measurements: a. can be excluded because of unexplained variance between passive and active motion. b. can be excluded if there is no patho-anatomic correlate. c. can be excluded if measurements between different evaluators vary by more than 10%. d. can be active or passive, depending on which is more consistent with clinical findings. 9. According to the AMA Guides (5th Edition), which of the following statements about rating impairment for spinal cord injuries is correct?

a. Because delayed recovery is common, impairments should not be estimated until at least two years after injury, even in cases which present as complete spinal cord lesions.

b. Impairments related to gait, use of upper extremities, respiration, bowel and bladder function, and sexual function are determined separately and then added to obtain the total whole person impairment. c. When impairments of trophic lesions, urinary calculi, osteoporosis,and reactive psychologic states occur in cord injured patients, the impairments should be rated separately and then combined with the spinal cord rating. d. Impairments related to gait, use of upper extremities, respiration, bowel and bladder function, and sexual function arecalculated, then the highest rating from the categories becomes the final rating.

10. Electrodiagnostic studies are most likely to be abnormal in which one of the following disorder: a. mild sensory neuropathy. b. early motor neuropathy. c. acute radiculopathy. d. peripheral nerve injury.

Answers to sample items

1. Answer: a 2. Answer: c 3. Answer: c 4. Answer: d 5. Answer: c 6. Answer: d 7. Answer: d 8. Answer: d 9. Answer: c 10. Answer: d

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Test Blueprint The description of examination content areas and bibliography are provided as general guides to assist you in preparing for the ABIME examination. The knowledge, skills, and abilities of the examinee will be tested in the content areas listed. The areas are weighted by both their significance and frequency encountered in a typical independent medical examination. The percentage refers to the relative weighting of these areas on the exam. 1. Clinical Competency 25% Candidates should demonstrate an understanding of pathophysiology, diagnostic evaluation (e.g., clinical history and interview process, physical examination and diagnostic studies), clinical management, health outcomes of neuro-musculoskeletal injuries, and familiarity with cardiopulmonary disease, neurological injuries, ear-nose-throat disorders, toxicology, controversial diagnoses, and other medical problems. The examination emphasizes clinical problems or situations encountered in performing independent medical examinations, or other types of “disability evaluations.”

a. Musculoskeletal (e.g., spinal, upper extremity, lower extremity disorders) b. Cardiopulmonary (e.g., pulmonary function and cardiac stress testing) c. Neurological (e.g., head injury, peripheral nerve dysfunction) d. Ear-nose-throat (e.g., hearing loss, dizziness, facial disfigurement) e. Toxicology (e.g., heavy metals, chemical exposure) f. Controversial diagnoses (e.g., multiple chemical sensitivities, chronic fatigue syndrome) g. Diagnostic techniques (e.g., laboratory, x-ray imaging, electrodiagnostic studies)

2. Behavioral Science 10% Candidates should demonstrate the ability to perform an assessment of behavioral disorders, to recognize the impact of behavior on injury, illness and disability, to recognize common psychiatric diagnoses and to assess appropriateness of care.

a. Behavioral assessment (e.g., mental status exam, psychosocial assessment, clinical assessment of dangerous patients, interpretation of pain drawings, basic interpretation of psychological testing, recognition of non-physiologic findings)

b. Psychiatric disorders (e.g., anxiety, organic brain syndromes, substance abuse, and personality, affective, and psychotic disorders)

c. Pain disorders and psychological factors (e.g., malingering, somatization, symptom magnification, factitious disorders)

3. Impairment and Disability Assessment 25% Candidates should demonstrate an understanding of the clinical assessment of functional ability, job demands, and definitions relevant to impairment disability evaluation.

a. Definitions (activities of daily living, impairment, disability, restrictions, limitations) b. Functional abilities assessment (e.g., functional capacity evaluation, validity indicators, job analysis, fitness for duty) c. US Department of Labor: Classifications for Physical Demand Characteristics of Work d. Medical statistics and epidemiology (e.g., sensitivity, specificity, mean, standard deviation, predictive value, reliability,

validity, study design) 4. Disability Systems 15% Candidates should demonstrate an understanding of compensation systems (e.g., workers’ compensation, Social Security, other federal systems, and personal injury). Included in this section are medicolegal definitions, rules of evidence, role of expert witness, the process of deposition and testimony, the role of the independent medical examiner, liability issues, and ethical behavior.

a. Workers’ compensation systems b. Social Security Administration c. Personal injury/tort d. Law and ethics e. Federal systems (e.g., Federal Employer’s Liability Act, Federal Employees’ Compensation Act) f. Americans with Disabilities Act – Title 1 (e.g., definitions, scope, reasonable accommodation, direct threat, undue

hardship) g. Family and Medical Leave Act

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5. AMA Guides to the Evaluation of Permanent Impairment and Report Writing 25% Candidates should demonstrate an understanding of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.

a. Concepts, principles and report writing (e.g., whole person concept, adding versus combining, ADL’s relationship to impairment, medical documentation, apportionment, causality, maximal medical improvement, components of a report, continuing care, future medical needs)

b. Neuro-musculoskeletal impairment evaluation (e.g., spine [DRE versus ROM], upper extremity, lower extremity, peripheral nervous system, neurological system)

c. Other systems (e.g., mental and behavioral, pain, cardiopulmonary)

ABIME Bibliography – Medical Exam The following readings are suggested. In addition to the texts listed below, the examinee should be familiar with pertinent journal articles in the general domains of orthopedics, neurology, occupational medicine, physical medicine, rehabilitation, behavioral science, psychology, chronic pain, and disability. The examinee should be familiar with the test blueprint, and not limit readings to the following material. Core Readings Guides to the Evaluation of Permanent Impairment. 6th Ed., Chicago, IL: American Medical Association; 2008 (ISBN1-57947-888-9). Suggested Readings Ranavaya MI, Rondinelli RD. The impairment and disability evaluations. In: Mayer TG, Gatchel RJ, Polatin PB, eds. Occupational Musculoskeletal Disorders: Function, Outcomes & Evidence. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2001. Rondinelli, RD. Impairment Rating and Disability Evaluation. Philadelphia, PA: Saunders, WB, 1999. Available through Elsevier Health Sciences 800-523-4069 X 2127 Aronoff, G. Evaluation and Treatment of Chronic Pain. Baltimore, MD Williams & Wilkins, 3rd Ed., 1999. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York, NY: Appleton-Century-Crofts, 1976. Kasdan M (ed). Occupational Hand and Upper Extremity Injuries & Diseases. Philadelphia, PA: Hanley & Belfus, Inc., 1991 LaDou, J. Occupational and Environmental Medicine, 2nd Ed. Stamford, CT. Appleton & Lang, 1997. Ranney D. Chronic Musculoskeletal Injuries in the Workplace. Philadelphia, PA: WB Saunders Company, 1997. Reference Materials Department of Labor: Physical Demand Characteristics of Work chart in Dictionary of Occupational Titles, 4th Ed, Revised, Vol. 1 and 2, Washington, DC, 1991. Diagnostic and Statistical Manual of Mental Disorders IV. Washington, DC: American Psychiatric Association; 1994 (ISBN 0-89042-061-0). Disability Evaluation Under Social Security. Washington, DC: Social Security Administration; September 1995. SSA Publication No. 64-039, ICN No. 468600. Technical Assistance Manual on the Employment Provisions (Title I) of the Americans with Disabilities Act. Washington, DC: Equal Opportunity Commission, 1992.

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AMERICAN BOARD OF INDEPENDENT MEDICAL EXAMINERS EXAM REGISTRATION FORM ~Please Complete All Pages of Application

The American Board of Independent Medical Examiners (ABIME) requests careful and thorough completion of this application form. Incomplete applications or errors will result in delay and possible disqualification. Applications MUST BE COMPLETED LEGIBLY and mailed or faxed to 304-733-5243. Completed application, supporting documentation as outlined below and payment of examination fee must arrive in the ABIME office no later than 2 weeks before the exam date listed to guarantee exam registration.

Documentation required with the Application Your file must be complete in order to receive exam results. The following items are required to complete your file:

1. Photocopy of medical degree or relevant diploma and current, and unrestricted medical license(s)/practitioner registration for the state/province/territory in which you practice and, if applicable, proof of ABMS Board Certification or other specialty certification.

2. Photocopy of a certificate of completion from an ABIME approved impairment and disability training program with at least 15 hours of continuing medical education. (After attending the ABIME training program you will receive a certificate of attendance and are then eligible to sit for the ABIME Certification Exam. Both training and exam can be done at the same ABIME training program.)

3. Two passport size photos & Current Curriculum Vitae.

Last Name: First Name: Middle Initial: ______

Medical School: City/State: Graduation Date (M/Y): _____/_______ Degree(s) (please circle): MD – DO – MB – DC – Other: ___________________ Professional License Issuing State, Territory or Province: _____________ Lic. #:_________________ Exp. Date: ______ Specialties:

Company (if applicable):

Address:

City: State/Province: Postal Code: Country:

Phone: (_____)___________ Fax: (_____)________________ E-Mail Address:

Please print your name, including credentials, as you would like it to appear on your certificate: U.S. Social Security Number/Canadian Insurance Number (if applicable): ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Please indicate the date and location of the exam for which you are applying: Examination Date: City/State:

Exam Payment - $995 US Funds:

r Payment by Check: Please make payable to ABIME r Payment by Credit Card: q Visa q MasterCard qAmex qDiscover

Card Number: ______________________________________________ Expiration Date:______/______ Verification Code: _________

Signature: Date:

EXAM REFUND POLICY: (Please read carefully as registering for any ABIME event constitutes your acknowledgement of the following) Please take notice that for the ABIME exam the fee is non-refundable after it is paid and can only be transferred to another exam location within the same calendar year for a $100 transfer fee. NO Substitutions are permitted. NO Exceptions Allowed. ABIME and its affiliates reserve the right to cancel or modify any activity for any reason with maximum liability of refund only of educational fees paid. ABIME and its affiliates hereby expressly disclaim any liability for damages incidental to or resulting from any cancellation or modification of any event. The laws of the state of West Virginia shall govern any disputes arising out of this agreement and venue shall lie exclusively in Cabell County, WV.

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ABIME Examinee Agreement:

In making this application for American Board of Independent Medical examiners’ (ABIME) certification exam and in consideration of its review and/or acceptance by the ABIME, I hereby agree to accept and be bound by all the terms and conditions governing ABIME exam and certification process, CIMETM status or CICETM status (should I pass the exam) as well as ABIME guidelines of conduct and with established examination administrative procedures and policies including the refund policy of ABIME as well as the Exam Agreement and General Instructions (all of which are available at www.abime.org), as they now exist and as they may be amended from time to time in the future.

In further consideration of acceptance of my exam application by ABIME for CIMETM status or CICETM status, I hereby further agree:

1. To indemnify and hold harmless the ABIME and each of its members of board of directors, trustees, officers, agents, employees and examiners, individually and collectively, from and against any claim or liability arising out of any act or omission related to or arising out of (a) the processing of this application, (b) the examination or the grading of it, or (c) the granting or failure to grant certification, recertification or CIMETM status or CICETM status;

2. That I will not receive and am not entitled to review my exam book or answer sheet once I have submitted them to ABIME after the exam. Nor would I demand or cause to demand on my behalf to receive or review my exam book or answer sheet or my exam grade or a copy of the exam report or related documents or to know of its contents, and I further understand that the contents of my exam report are confidential. I also agree that I would receive my exam result only in pass or fail grade and that the ABIME is the final arbiter of my exam results and its decision regarding my exam result shall be final and binding on me; 3. That any certificate of CIMETM status or CICETM status or any diplomate status issued to me shall be and shall remain the property of the ABIME and that I shall promptly return the certificate to the ABIME in the event my status as a CIMETM is terminated, either voluntarily or by action of ABIME or when it expires as stated on the certificate;

4. That the CIMETM status or CICETM status or any ABIME granted diplomate status is not for life and is therefore time limited and I hereby pledge to continue re-certification of the CIMETM status or CICETM status as prescribed by ABIME every five years; If I fail to do so, I promise to refrain from using or displaying the CIMETM status or CICETM status with my name. I further agree that after expiry of my CIMETM status or CICETM status and without recertification; my continuing use of the CIMETM status or CICETM status or any diplomate status shall constitute professional dishonesty and a breach of ABIME code of conduct;

5. That I am obligated to inform the ABIME immediately of any change in my status as described in this application occurring after its submission, and I understand that my failure to so inform the Board is grounds for my disqualification as a candidate for examination or as a CIMETM status or CICETM status or any ABIME granted diplomate status, if I am recertified;

6. That my name, along with names of all doctors certified with CIMETM status or CICETM status or any ABIME granted diplomate status of the American Board of Independent Medical examiners will be published in ABIME’s Board of registry international Directory of certified Specialists, and will be posted on and the ABIME web site (www.theABIME.org). I understand that this information is available to the public;

7. This application for ABIME exam and in consideration thereof the resulting agreement entered into as above between myself and ABIME shall be governed by and construed in accordance with the laws of the State of West Virginia, regardless of the law that might otherwise govern under applicable principles of conflicts of laws thereof. The parties further agree that any suit, action or proceeding arising out of, or with respect to, this agreement, or any judgment entered by any court in respect thereof shall be brought in the courts of the State of West Virginia and venue shall lie exclusively in Cabell County, West Virginia.

8. I warrant that each of the statements made in support of this application are true and correct. I hereby authorize ABIME to request information from organizations referred to in this application, and to verify academic and/or clinical training and licensure deemed necessary to make a determination of my eligibility. Applicant’s Signature: Date:

Exam Application Reviewed by ABIME: Initial: Date:

Approval of Exam Application by ABIME: Signature: _______ Date:

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ABIME Guidelines of Conduct: Each doctor certified by the American Board of Independent Medical Examiners (ABIME) has agreed to comply with these guidelines of conduct: Physicians should:

1. Be honest in all relevant communications; 2. Respect the rights of the examinees and treat them with dignity and respect; 3. At the medical examination:

a. Introduce himself/herself to the examinee as the examining physician; b. Advise the examinee they are seeing him/her for an independent medical examination, and

the information provided will be used in the assessment and presented in a report; c. Provide the examinee with the name of the party requesting the examination, if requested; d. Advise the examinee that no treating physician-patient relationship will be established; e. Explain the examination procedure; f. Provide adequate draping and privacy if the examinee needs to remove clothing for the

examination; g. Refrain from derogatory comments; and h. Close the examination by telling the examinee that the examination is over and ask if there is

further information the examinee would like to add. 4. Reach conclusions that are based on facts and sound medical knowledge and for which the examiner

has adequate qualifications to address; 5. Be prepared to address conflict in a professional and constructive manner; 6. Never accept a fee for services which are dependent upon writing a report favorable to the referral

service; 7. Maintain confidentiality consistent with the applicable legal jurisdiction.

After completing all pages of this application, include payment and mail or fax, along with a copy of your Current and Unrestricted Medical License and Current Curriculum Vitae to:

ABIME at 6470-A Merritts Creek Road, Huntington, WV 25702 Call (304) 733-0095 or (304) 733-0096; Fax (304) 733-5243;

Email us at [email protected] OR Visit our website at www.abime.org

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ABIME National Directory Survey Survey answers are used for the ABIME National Directory Listing of each physician.

1. Number of Years of Residency Training: _____ 2. Number of Years of Medical Practice: _____

(Minimum 5 years of practice required; however, if ABMS Board Certified, this requirement may be waived. Please provide proof of ABMS Board Certification.)

3. Years Experience in Performing Impairment and Disability Evaluations: _____ 4. Approximate Number of Examinations You Have Performed: _____ 5. Number of Times Deposed: _____ 6. Additional Degrees in Health-Related Fields (E.G., M.P.H., Phd., Or Other): __________________________________________________ 7. Other Training in Impairment and Disability Evaluation: __________________________________________________ 8. Total Hours of AMA Category 1 CME training on impairment & disability evaluation completed within the past three years: _____ 9. ABMS Board Certifications (proof must be submitted in order to list as Board Certified in the Directory): _________________________________________ 10. Memberships in Specialty Organizations: __________________________________________________ 11. Office Manager/Office Contact: Name: ______________________________ Phone: ______________________ E-mail: ______________________________ Fax: _______________________

I Hereby Authorize ABIME To Request Information From Organizations Referred To In This Application, And To Verify Academic And/Or Clinical Training And Licensure Deemed Necessary.

Signature: Date:

ABIME at 6470-A Merritts Creek Road, Huntington, WV 25702 Call (304) 733-0095 or (304) 733-0096; Fax (304) 733-5243;

Email us at [email protected] OR Visit our website at www.abime.org

15

American College of Disability Medicine & American Board of Independent Medical Examiners Joint Sponsored by Marshall University Joan C. Edwards School of Medicine

Presents

Segment One – 15 hrs AMA Category 1 CME Credit AMA Guides 6th Ed. to the Evaluation of Permanent Impairment

Training Course and Certification Review

Cost: $895.00 US Funds Course #RVW Intended Audience: Physicians from a variety of Specialties

Presented By: Mohammed I. Ranavaya, MD, JD, MS, FFOM, FRCPI, CIME: Dr. Ranavaya is a Professor of Occupational and Environmental Medicine at the Marshall University School of Medicine in West Virginia. Robert D. Rondinelli, MD. PhD: Is board certified in Physical Medicine and Rehab. He is editor in chief of the AMA Guides 6TH Ed. Kathryn L. Mueller, MD, MPH, CIME: Dr. Mueller works for the National Jewish Medical Center in Denver, Colorado and is one of the founding members of ABIME. Dr. Mueller is board certified in Occupational Medicine. Robert B. Walker, MD: Is board certified in Occupational Medicine and Family Medicine. He currently serves as Vice Chancellor for Health Sciences for West Virginia Higher Education Policy Commission. This course is specifically designed to educate and prepare physicians in the use of the AMA Guidelines to the Evaluation of Permanent Impairment, 6th edition.

Educational Objectives • At the conclusion of this learning activity, participants should be able to: • Describe the knowledge content related to the A MA Guides 6th Edition. • Discuss new developments in the A MA Guides 6th Edition. • Differentiate symptoms, pathology, impairment, function and disability • Explain the fundamentals of quality disability evaluation services • Relate clinical data to case issues and discuss skills needed to perform evaluations • Perform musculoskeletal permanent impairment ratings according to the AMA Guides to the Evaluation of Permanent Impairment. • Utilize skills to perform complex case evaluations of musculoskeletal pain disorders • Explain the use of other chapters of the AMA Guides 6th Edition. • Define the steps needed to implement the use of the AMA Guides 6th Edition in your practice.

Practical Objectives • Perform impairment evaluations according to the AMA Guides 6th Edition. • Demonstrate skills in evaluating complex cases • Evaluate and manage difficult impairment evaluations patients • Perform excellent independent medical evaluations • Provide IME services and serve as an expert medical witness • Improve the quality of medical reports PROGRAM SCHEDULE: A comprehensive review of the AMA Guides to the Evaluation of Permanent Impairment, 6th ed. Day 1 7:00 a.m. Registration and Continental Breakfast 7:30 a.m. Welcome & Introduction and review of course objectives 7:45 a.m. Key concepts, philosophy and underlying principles of the AMA Guides, Chapters 1 and 2 9:45 a.m. Morning Refreshment Break 10:00 a.m. Spine Impairment Rating with Case Presentation 12:15 p.m. Lunch and learn with the faculty, Questions/Answers, Discussion 1:15 p.m. Upper Extremities Impairment Rating with Case Presentations 3:00 p.m. Afternoon break 3:15 p.m. Lower Extremities Impairment Rating 4:00 p.m. Beyond Musculoskeletal Systems, An overview of Chapters 4-12 of the AMA guides and non-musculoskeletal systems mock questions 6:00 p.m. Adjourn

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Day 2 7:00 a.m. Registration and Continental Breakfast 7:30 a.m. More AMA Guides 6th Edition Case Presentations 8:30 a.m. A primer on Biostatistics, controversial diagnoses and other issues on the exam 9:00 a.m. What is the ABIME exam about? An introduction and some tips for MCQ exams 9:30 a.m. Mock exam questions and practice 10:00 a.m. Morning Refreshment Break 10:15 a.m. Impairment Rating of the Nervous System 11:00 a.m. Impairment Rating for Mental and Behavioral Disorders 12:15 a.m. Impairment Rating for Pain 1:00 p.m. Adjourn

*The International Program differs slightly from the above schedule.

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Marshall University Joan C. Edwards School of Medicine and ACDM/ABIME. Marshall University Joan C. Edwards School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Marshall University Joan C. Edwards School of Medicine designates this educational activity for a maximum of 39 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Segment registration and attendance verification are required.

Segment Two – 8 hrs AMA Category 1 CME Credit A Doctor’s Guide to Practical Use of the AMA Guides to the

Evaluation of Permanent Impairment 5th Edition– An Overview Cost: $595.00 US Funds Course # OVW Intended Audience: Physicians from a variety of Specialties Presented By: Mohammed I. Ranavaya, MD, JD, MS, FACPM, CIME: Dr. Ranavaya is a Professor of Occupational and Environmental Medicine at the Marshall University School of Medicine in West Virginia. Kathryn L. Mueller, MD, MPH, CIME: Dr. Mueller works for the National Jewish Medical Center in Denver, Colorado and is one of the founding members of ABIME. Dr. Mueller is board certified in Occupational Medicine. Robert D. Rondinelli, MD. PhD: Is board certified in Physical Medicine and Rehab. He is editor in chief of the AMA Guides. Robert B. Walker, MD: Is board certified in Occupational Medicine and Family Medicine. He currently serves as Vice Chancellor for Health Sciences for West Virginia Higher Education Policy Commission. Faculty does not have any disclosures to make

This course is specifically designed to educate and prepare physicians in the use of the AMA Guidelines to the Evaluation of Permanent Impairment.

Educational Objectives

At the conclusion of this learning activity, participants should be able to: • Perform an independent medical evaluation based on the AMA Guides 5th Edition. • Explain and present the differences between impairment, function and disability. • Discuss the critical steps involved in the impairment evaluation using the AMA Guides in clinical practice. • Describe the knowledge content related to the AMA Guides 5th Edition. • Discuss new developments in the AMA Guides and explain the main differences between the various editions of the AMA Guides. • Relate clinical data to case issues and perform evaluations. • Perform musculoskeletal permanent impairment ratings according to the AMA Guides 5th Edition. • Explain the use of internal medicine, pain and psychiatric chapters of the AMA Guides.



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Segment Two – 8 hrs AMA Category 1 CME Credit

A Workshop on Building A Successful Independent Medical Examiner/Expert Witness Practice (Course No. IEW)

Cost: $695.00 US Funds Course #IEW Intended Audience: Physicians from a variety of Specialties

Presented By: Mohammed I. Ranavaya, MD, JD, MS, FACPM, CIME: Dr. Ranavaya is a Professor of Occupational and Environmental Medicine at the Marshall University School of Medicine in West Virginia.

This course is specifically designed for Physicians/Surgeons of all specialties and Chiropractic Doctors and others to learn a nuts and bolts approach to start, build and successfully run a Independent Medical Examiner/Expert Witness Practice either part-time or full time.

This is an interactive workshop with a hands on approach to learning the skills required in dealing with Lawyers and the legal system as a medical expert witness. The format is mainly audience participation, including mock deposition and trial testimony from volunteer participants. Whether you are a beginner or experienced you will find this training very useful in enhancing your skills in dealing with legal issues related to your role as Independent Medical Examiner/Expert Witness.

Educational Objectives At the conclusion of this learning activity, the participants should be able to:

• Reveiw the need for evidence based scientific testimony in Medicolegal cases • Describe ethical and professional conduct as Medical Expert Witness • List the key components of a successful Independent Medical Examiner/Expert Witness Practice • Discuss various issues commonly addressed in an Independent Medical Examiner/Expert Witness Practice • Describe how to deal with questions on direct and cross examination during deposition and trial testimony of an

Independent Medical Examiner/Expert Witness • Discuss the proper preparation for deposition and trial testimony • Discuss how best to deal with the abusive attorneys and their tactics


Marshall University Joan C. Edwards School of Medicine designates this educational activity for a maximum of 8 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Segment registration and attendance verification are required.

Segment Five – 4 hrs AMA Category 1 CME Credit

Evidence Based Scientific Approach to Detection of Malingering & Deception During IMEs

Cost: $350.00 US Funds Course# MAL Audience: Physicians from a variety of Specialties

Presented By: Francosis Sestier, MD, MPH, CIME: Dr. Sestier is a Professor of Insurance Medicine at University of Montreal, Canada. He is Board Certified, in Cardiology, Pulmonary, Occupational and Aerospace Medicine.

Faculty does not have any disclosures to make

This course is specifically designed to educate and prepare physicians in the use of the AMA Guidelines to the Evaluation of Permanent Impairment.

Course Objectives At the conclusion of this learning activity, participants should be able to:

• Interpret incidence of exaggeration and deception during an IME. • Discuss the difficulties in detecting physical and verbal indicators of malingering. • Apply Symptom Validity Tests. • Define clinical skills necessary to identify malingering.

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Marshall University Joan C. Edwards School of Medicine and ACDM/ABIME. Marshall University Joan C. Edwards School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Marshall University Joan C. Edwards School of Medicine designates this educational activity for a maximum of 39 AMA PRA Category 1

Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Segment registration and attendance verification are required.

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Segment Three – 4 hrs AMA Category 1 CME Credit Medicolegal Issues for Independent Medical Examiners and Expert Witness: A Workshop Facilitator: Prof. Mohammed I. Ranavaya, MD, MS, JD, FFOM, FRCPI, CIME 4 hours of AMA Category 1 CME. Educational Tuition is US $350. Course # MLG. Intended Audience: Physicians of all specialties. Others who would benefit from this workshop include physicians’ assistants and nurse case managers. This 4-hour workshop is designed to teach physicians who perform independent medical examinations and serve as expert witnesses the skills critical to effectively deal with lawyers and the legal system. COURSE OBJECTIVES: • Increase effectiveness in practice through a better understanding of the disability and compensation systems and the related law in the US. • Learn the critical steps involved in providing medical expert witness and independent medical examination services. • Understand the liabilities and risks for independent medical examiners and how to manage those risks. • Learn essential skills for deposition and other testimony in court. • Improve the knowledge of medicolegal considerations for independent medical examiners.



Segment Four – 4 hrs AMA Category 1 CME Credit Clinical Practice Evidence Based Guidelines

Facilitator: Kathryn L. Mueller, MD, MPH, FACOEM,CIME 4 hours of AMA Category 1 CME - Educational Tuition is US $350 - Course# CPG - Audience: Physicians from a variety of Specialties This course is specifically designed to educate and prepare physicians in the use of the Clinical Practice Evidence Based Guidelines

COURSE OBJECTIVES At the conclusion of this learning activity, participants should be able to: • State at least 5 characteristics of quality evidence-based clinical practice guidelines. • Apply these characteristics to an existing guideline and properly identify the guideline’s weaknesses and strengths. • Describe the basic practice principles in the ACOEM clinical practice guidelines. • Explain the ACOEM clinical practice guideline recommendations for spinal surgery, discograms, and spinal cord stimulators and

apply them to case examples. • List the requirements for medical management of chronic pain and opioid use in non-malignant pain per the ACOEM clinical

practice guidelines


Marshall University Joan C. Edwards School of Medicine designates this educational activity for a maximum of 39 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Segment registration and attendance verification are required. .

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Segment Five – 4 hrs AMA Category 1 CME Credit

Causation In Medicolegal Claims, What does the science say? A Workshop Facilitator: Kathryn L. Mueller, MD, MPH, FACOEM,CIME 4 hours of AMA Category 1 CME - Educational Tuition is US $350 - Course# CAS - Audience: Physicians from a variety of Specialties This course is specifically designed to educate and prepare physicians in the use of the AMA Guidelines to the Evaluation of Permanent Impairment. COURSE OBJECTIVES At the conclusion of this learning activity, participants should be able to: • Define standards for causality used in medical legal contexts • Interpret medical evidence and scientific literature for causality analysis • Apply steps for the medical legal causality analysis to cumulative trauma and other controversial cases • Discuss the difficulties in interpreting common degenerative disease findings as causally based using spinal injuries as case examples



Segment Six – 4 hrs AMA Category 1 CME Credit How to Write Winning Reports Workshop

Facilitator: Prof. Mohammed I. Ranavaya, MD, MS, FFOM, FRCPI, CIME 4 hours of AMA Category 1 CME. Educational Tuition is US $350. Course # RPT. Intended Audience: Physicians of all specialties. This 4-hour workshop is designed to focus on the skills necessary to write winning reports in the medicolegal arena. Learn the necessary skills from an expert who has written thousands of persuasive IME reports. COURSE OBJECTIVES This 4 hour seminar will discuss how to write a report that • Communicates information that readers need. • Presents information accurately and convincingly. • Establishes your credibility and professionalism to a reader. • Structures material so readers can find information quickly and easily. • States key points clearly and without ambiguity so that readers can understand your meaning. • Uses language and sentence structure that lay readers can follow.



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Segment Two – 4 hrs AMA Category 1 CME Credit Return to Work and Fitness for Duty Decisions –

How to Use a Function Based Approach Workshop (Course No. RTW) Cost: $350.00 US Funds Course #RTW Intended Audience: Physicians from a variety of Specialties Facilitator: Randy Soo Hoo, MD, MPH, FACOEM, CIME

COURSE OBJECTIVES At the conclusion of this learning activity, the participants should be able to:

• Define terms and concepts commonly used in Return to Work, Fitness for Duty, and disability determinations. • Correlate biomechanical and medical consideration to functional elements of work. • Discuss clinical tools used to evaluation physical functional capacity • Provide strategies for completion of Return to Work, Fitness for Duty, and disability forms.

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Marshall University Joan C. Edwards School of Medicine and ACDM/ABIME. Marshall University Joan C. Edwards School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.


Segment Five – 4 hrs AMA Category 1 CME Credit Traumatic Brain Injuries and Concussion Claims

How to Evaluate Them – A Workshop

Cost: $350.00 US Funds Course# TBI Intended Audience: Physicians from a variety of Specialties Facilitator: Gerald S. Steiman, MD, CIME COURSE OBJECTIVES At the conclusion of this learning activity, participants should be able to: • Discuss the diagnostic criteria and have a detailed knowledge of the various somatic, behavioral and cognitive complaints which

accompany traumatic brain injuries. • Conduct a through evaluation of claims of concussion and be able to diagnose a post concussive syndrome. • Interpret the commonly encountered neuropsychological tests. • Discuss the recovery profile following a concussion. • Apply the knowledge to clinical practice based on the current scientific literature.

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Marshall University Joan C. Edwards School of Medicine and ACDM/ABIME. Marshall University Joan C. Edwards School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.


The training programs offered here are neither authorized nor sponsored by AMA.

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